2022 CSACI annual scientific meeting book of abstracts

Background: Allergic asthma is present in approximately 60% of adult patients with severe asthma. Tezepelumab, a human monoclonal antibody, blocks thymic stromal lymphopoietin (TSLP). This post hoc analysis evaluated the efficacy of tezepelumab with increased statistical precision in patients with severe, uncontrolled asthma and perennial aeroallergen sensitization using pooled data from the phase 2b PATHWAY and phase 3 NAVIGATOR studies. Methods: PATHWAY (NCT02054130) and NAVIGATOR (NCT03347279)

Background: Allergic asthma is present in approximately 60% of adult patients with severe asthma.Tezepelumab, a human monoclonal antibody, blocks thymic stromal lymphopoietin (TSLP).This post hoc analysis evaluated the efficacy of tezepelumab with increased statistical precision in patients with severe, uncontrolled asthma and perennial aeroallergen sensitization using pooled data from the phase 2b PATHWAY and phase 3 NAVIGATOR studies.Methods: PATHWAY (NCT02054130) and NAVIGATOR (NCT03347279) were multicentre, randomized, double-blind, placebo-controlled studies with similar designs.Patients who received tezepelumab 210 mg or placebo subcutaneously every 4 weeks for 52 weeks and had a positive or negative fluorescence enzyme immunoassay test for serum-specific immunoglobulin E against at least one perennial aeroallergen were included in this analysis.The annualized asthma exacerbation rate (AAER) over 52 weeks (primary endpoint in both trials) and the annualized rate of exacerbations that required hospitalization or an emergency department (ED) visit over 52 weeks were assessed in patients grouped by perennial allergic status.Results: Overall, 1299 patients were included; 815 (63%) had perennial aeroallergen sensitization and 484 (37%) did not.Tezepelumab reduced the AAER over 52 weeks compared with placebo by 62% (95% CI: 53-70) in patients with perennial aeroallergen sensitization and by 54% (95% CI: 38-66) in those without.The annualized rate of exacerbations that required hospitalization or an ED visit was reduced with tezepelumab compared with placebo by 80% (95% CI: 61-90) in patients with perennial aeroallergen sensitization and by 74% (95% CI: 41-88) in those without.Conclusions: Tezepelumab reduced exacerbations compared with placebo, including those that required hospitalization or an ED visit, in patients with severe, uncontrolled asthma with or without perennial aeroallergen sensitization.These findings further support the benefits of tezepelumab in a broad population of patients with severe, uncontrolled asthma, including those with allergic and non-allergic asthma.
Background: Patients with moderate-to-severe asthma may be at risk of accelerated lung function decline (LFD).Currently, there are limited data on prognostic and predictive biomarkers for LFD.Dupilumab, a human monoclonal antibody, blocks interleukin 4/13 signaling, key and central drivers of type 2 inflammation.In phase 3 QUEST (NCT02414854), dupilumab improved lung function and was generally well tolerated.Here we assessed baseline characteristics associated with rapid LFD in patients who received placebo during QUEST and the effect of dupilumab on LFD.Methods: Baseline characteristics were assessed in patients who received placebo during QUEST with rapid (> 2%/year) or no (< 1%/year) LFD (defined as post-bronchodilator FEV1 percent change).To evaluate the predictive/prognostic role of biomarkers, LFD was evaluated across different baseline blood eosinophil (eos) (< 150, ≥ 150, ≥ 300 cells/ mL) and FeNO (< 25, ≥ 25, ≥ 50 ppb) thresholds across dupilumab and placebo populations.Results: Placebo patients with rapid LFD had higher baseline FeNO levels (36 ppb, n = 271) compared with patients without LFD (27 ppb, n = 49), but similar eos.Placebo patients with elevated baseline FeNO had greater lung function decline, irrespective of baseline eos: LFD in placebo patients with high baseline FeNO ≥ 25 and ≥ 50 combined with low eos < 150 was − 116 mL/year (n = 53) and − 102 mL/year (n = 20), respectively, compared to − 56 mL/year (n = 187) and -71 mL/ year (n = 90) in patients with low FeNO < 25 and high eos ≥ 150 and EOS ≥ 300, respectively.LFD was attenuated in dupilumab-treated patients across populations, ranging from + 43 (n = 27) to + 4 (n = 99) in the high FeNO/low eos group and from − 17 (n = 363) to − 35 (n = 172) in the low FeNO/high eos group.Conclusions: FeNO was elevated in patients with rapid LFD vs no LFD.High baseline FeNO levels were associated with greater LFD in placebo patients, which was attenuated in dupilumab-treated patients, suggesting FeNO may be prognostic for accelerated LFD and predictive of the treatment response to dupilumab.
Background: Prior asthma exacerbations have been associated with lung function decline and increased risk of future exacerbations.Dupilumab, a human monoclonal antibody, blocks the shared receptor component for interleukins 4/13, key and central drivers of type 2 inflammation in multiple diseases.In phase 3 QUEST (NCT02414854), add-on dupilumab significantly reduced exacerbations and improved lung function in patients with uncontrolled, moderate-to-severe asthma.The TRAVERSE open-label extension study (NCT02134028) evaluated dupilumab long-term safety, tolerability, and efficacy in patients from a previous dupilumab asthma study.Dupilumab safety during TRAVERSE was consistent with the known safety profile.This post hoc analysis examined the relationship between prior exacerbations and lung function in patients with type 2 asthma (blood eosinophils ≥ 150cells/μL or FeNO ≥ 25 ppb at baseline) from QUEST enrolled in TRAVERSE.Methods: Patients who received placebo or dupilumab in QUEST received dupilumab 300 mg every 2 weeks in TRAVERSE for up to 48/96 weeks (placebo/dupilumab and dupilumab/dupilumab groups).This analysis assessed annualized severe exacerbation rates (AER) and change from baseline in % predicted (pp) FEV 1 in non-exacerbators (0 exacerbations) and exacerbators (≥ 1 exacerbations) during QUEST.Results: In the exacerbator group, dupilumab reduced AER vs placebo in QUEST (1.67 vs 2.59, respectively); AER was low in TRAVERSE (dupilumab/dupilumab 0.78, placebo/dupilumab 0.56).In the nonexacerbator group, dupilumab maintained low AER (dupilumab/ dupilumab 0.11, placebo/dupilumab 0.17) in TRAVERSE.Mean ppFEV Background: Dietary avoidance is essential to prevent a potentially fatal allergic reaction.This near-constant need for dietary vigilance contributes to a social burden, including excess food costs and poorer mental health, for families who manage food allergy.Herein, we aimed to describe the financial and mental health impact of the first three months of a biweekly delivery of food allergy-friendly grocery kits to Winnipeg families managing milk allergy.Methods: As part of an interventional study, we enrolled 10 Winnipeg families whose children aged ≤ 6 years with allergist-diagnosed milk allergy, and who had a net annual household income of less than $70,001.Families were recruited via social media and word-of-mouth.The intervention consisted of a bi-weekly, contactless home delivery (or elsewhere, by mutual agreement) of food allergy-friendly grocery kits, valued at ~ $75/kit.At baseline and midpoint (3 months after the start of the intervention), families completed a series of questionnaires on food costs and mental health.Results: In total, the 10 participating families enrolled had an average monthly income of $3493.81.Surveys were completed exclusively by mothers.Children with milk allergy were age 3.0 ± 1.4 years, on average, and were ethnically diverse.In addition to milk, other food allergies were reported, most commonly to eggs, peanut and soy (n = 4 each).At baseline, monthly food costs averaged $736.36 ± $387.36, which decreased at midpoint to $673.75 ± 201.28, representing a nonstatistically significant decrease of $62.61, or 8.5%.Regarding mental health from baseline to midpoint, generalized anxiety, depression and perceived stress did not change (all p ≥ 0.60).Mothers' perceived life status, assessed using a visual analogue scale from 1-10, nonstatistically significantly increased by 10.5% (baseline 6.82 ± 0.48; midpoint 8.0 ± 0.46).Conclusions: Within three months, this unique intervention to support low-income families managing food allergy had reduced grocery costs, despite globally increasing food prices, and shows modest gains in perceived life status.community to provide education to the families of children (0-17 years) with asthma, food allergy, and eczema.Parents were emailed a Microsoft Teams link for a 60-min session with a Certified Asthma Educator with experience in food allergy and eczema education.The nurse educators used PowerPoint slides and other visual aids to demonstrate correct inhaler, epinephrine auto-injector, and topical treatment techniques.Following the sessions, families were emailed electronic asthma, food allergy, and/or eczema resources and an anonymous SurveyMonkey ® questionnaire link.Results: CAAEC received 217 questionnaire responses for one or more of asthma (46.1%), food allergy (59.9%), and eczema (38.7%) education for children ages 0-6 years (83.9%),7-11 years (12.9%), and 12-17 years (3.2%).Most participants reported that they had all their questions answered (97%), learned a great deal of new information (72%), found the information useful (87%) and clear (95%), and better understood how to manage (92%), and felt more confident in the management of (90%) their child's asthma, food allergy, and eczema.Conclusions: Virtual sessions with a qualified allergy nurse educator were a positive experience for parents, met their education needs, and improved their knowledge of and confidence in managing their child's allergic condition.Virtual education continues to be offered as part of CAAEC programing.Further research evaluating its cost and accessibility would be useful.
Background: Atopic dermatitis (AD) is associated with significant impairment of caregivers' and children's quality of life.Treatment for this inflammatory skin disease is not curative and long-term daily maintenance therapy is required to prevent chronic relapses.The CAAEC developed an education program to help caregivers gain knowledge and skills to manage AD.Our goal was to evaluate knowledge, behavior change, and caregiver satisfaction following an eczema education session.Methods: The standardized Eczema Education Program was developed and directed towards children and teens with moderateto-severe AD, and their caregivers.The program included a knowledge portion, direct demonstration of the application of emollients and prescribed medications, and specialized interventions such as wet wraps.Prior to April 2020, education was offered in person.Due to the COVID-19 Pandemic, most subsequent education sessions were provided virtually via Microsoft Teams video conferencing.A caregiver satisfaction questionnaire was emailed to families via Survey Monkey ™ post education.Results: Between June 2020 and June 2022, 23 participants responded to the questionnaire and reported: • better ability to recognize early signs of eczema flare (87%), • improved understanding of management strategies (82%) • increased use of moisturizers (78%) • fewer eczema flares (56%).
• that they would contact the educator in the future for questions and support (87%).
Information identified as "very useful" included: physiology of eczema, information about bathing, application of moisturizers, use of topical medicated creams, tips for managing itch and the availability of the educator for ongoing support.)).Oral desensitization was performed using one of two strategies according to the allergist: initial doses were either tahini muffin (69.2%) or sesame seeds (41.9%).To date, 7 patients (22.6%), after an average of 7.4 visits, reached the maintenance dose.Among the 8,515 total intake doses of sesame, 13 cases of non-anaphylactic allergic reactions and 1 case of anaphylaxis occurred.Over half (57.1%) of the reactions occurred at clinic during first visit or updosing.There were significantly more non-anaphylactic allergic reactions to sesame seeds than to tahini muffin (p-value = 0.016).
Conclusions: Modified sesame desensitization protocols can be safely used in children with sesame allergy.

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Safety and efficacy of early oral immunotherapy for peanut allergy in a primary care setting Victoria Landry 1 , Christopher Vaillancourt 1,2,3 , Kavish Chandra Background: Peanut allergy is a common food allergy that can cause life threatening anaphylaxis.Early oral immunotherapy for peanut allergy (P-EOIT) has been shown to be effective and safe in research and specialty clinic settings.New Brunswick has limited access to specialty allergy care, and provision of P-EOIT in primary care would make it available to more patients.We sought to assess the safety and efficacy of successful P-EOIT completion in a primary care setting, along with rates of peanut-related allergic reactions leading to emergency department (ED) visits and use of epinephrine.
Methods: This study included all patients starting P-EOIT under 36 months old at a primary care allergy clinic in New Brunswick, Canada from 2016 to 2020.Patients had a history of allergic reaction to peanut with a positive skin prick test or positive peanut specific IgE level (ps-IgE), or ps-IgE ≥ 5 kU/L with no history of peanut allergy.
Patients had biweekly clinic visits with graded increase in peanut protein up to a maintenance dose of 300 mg peanut protein daily.A blinded retrospective chart review was conducted along with phone interviews regarding ED visits and epinephrine use.This study was approved by our Regional Research Ethics Board.
Results: Of 69 consented patients, 67 (97.1%) were followed up successfully.All consented patients reached maintenance dose, over a median of 29 weeks, and 66 patients (95.7%) were still regularly consuming peanut protein after one year of maintenance.One patient had a peanut ingestion-related ED visit requiring epinephrine during the escalation phase of peanut protein dose (1.5%; 95% CI 0.0 to 8.0%).
During the first year of maintenance phase, no patients had peanut ingestion-related ED visits or required epinephrine.Conclusions: P-EOIT in a primary care setting appears to be safe and effective with the majority of patients reaching the maintenance phase.

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The effectiveness of oral immunotherapy on food allergy related quality of life Benjamin J. Lawson Background: Food allergies have become increasingly common in North America, and place many patients at risk of severe, lifethreatening allergic reactions.A lower health-related quality of life may be experienced by families with food-allergic children as a result of anxiety related to the possibility of accidental exposure and psychosocial consequences.We seek to assess the effect of successful Oral Immunotherapy (OIT) on parent-reported quality of life given a growing body of evidence that shows it can greatly reduce the risks associated with food allergies.Methods: Children with a convincing history of allergy diagnosed via a positive skin prick test to either sesame, peanut, or walnut were recruited at the Montreal Children's Hospital and The Children's Clinic located in Montreal.Parents of participants were assessed using a Food Allergy Quality of Life Questionnaire-Parent Form (FAQLQ-PF) at baseline prior to desensitization, and again after participants had reached maintenance (Either 2 teaspoons of hummus, ¼ teaspoons of peanut butter, or 1/8 walnut, dependent on allergen).A nonparametric test was conducted to detect differences in the scores at baseline and at follow-up.
Results: 14 Children (57% female, median age = 1.8 years) were included in the study.Participants had undergone desensitization for peanut (79%), sesame (14%) and walnut (7%).No significant difference between total FAQLQ-PF scores at baseline and at follow up were found (p = 0.391).Similarly, no significant differences were found in the scores of the Food Anxiety (p = 0.906), Emotional Impact (p = 0.149), and Social/Dietary Restriction (p = 0.972) subscales.A significant difference was found between the baseline and follow-up scores of the subscale assessing parental concern regarding accidental exposure (p = 0.037), but not in the subscale assessing the child's level of concern regarding accidental exposure (p = 0.447).Background: Data on long-term adherence and efficacy of oral immunotherapy (OIT) is sparse.We aimed to assess long-term adherence and the risk of allergic reaction after attaining OIT maintenance.Methods: Thirty-six children who reached their OIT maintenance dose of 200 ml milk were followed at the Montreal Children's Hospital.Patients were queried annually on milk consumption and allergic reactions.Survival analysis was performed to evaluate the association between the risk of reaction and adherence to OIT.

Conclusions
Results: Patient ages ranged from 8 to 21 years old (median 15, 50% male).Median follow-up time after beginning maintenance was 2.5 years (range 0.4-5.4years).Eighteen patients (50%) adhered to OIT protocol (≥ 200 ml milk, ≥ 3 times per week), 3 patients (8%) partially adhered (< 200 ml milk or baked goods, ≥ 3 times per week), 6 patients (17%) did not adhere (dairy products 1-2 times per week), and 9 patients (25%) stopped ingesting dairy products.Reactions occurred in 13 patients (36%).Background: Good's syndrome is a rare adult-onset combined immune deficiency, characterized by thymoma and hypogammaglobulinemia.Patients present late in disease, following recurrent sinopulmonary infections, opportunistic infections, cytopenias, absent B cells and T-cell abnormalities.Documentation of the long term clinical and laboratory evolution is lacking due to the rarity of the disease and the relative lack of cohort studies.Methods: We report a longitudinal, single site, case series of seven patients from 1980 to present.Demographics, clinical presentation including age at key events including: hypogammaglobulinemia, immunoglobulin replacement, and death were collected along with the type and frequency of infections, and thymoma pathology.Clinical and laboratory evolution over time, including quantitative immunoglobulins, complete blood count, B and T cell numbers and function were documented.Results: Mean age at thymoma diagnosis was 51, of hypogammaglobulinemia was 50, and of immunoglobulin replacement was 58.5.In 5/7 patients, thymoma pathology was WHO type AB.All patients had absent B cells, and all but one patient were severely hypogammaglobulinemic.All but one patient developed recurrent sinopulmonary infections prior to the thymoma.All demonstrated in vitro and in vivo T cell dysfunction, on either lymphocyte proliferation testing or delayed-type hypersensitivity skin testing.Clinical history was notable for opportunistic and chronic bacterial infections.Cytopenias appeared to emerge with advanced disease in 4/7 patients.Two patients are deceased: one patient from progressive multifocal encephalopathy due to polyoma virus at age 69, another with systemic cytomegalovirus and subsequent septic shock from pseudomonas pneumonia at age 71.Conclusions: During the last 4 decades, we systematically documented the natural history of seven patients with Good's syndrome.Clinical and laboratory evolution of these patients provides crucial longitudinal information about the disease progression and will support efforts to better characterize this rare disease.Background: The ability of B cells to regulate immunity, beyond antibody production, resulted in the classification of a novel subset of B-cells, called regulatory B-cells (Breg).The identification of this subset was initially based on their ability to attenuate inflammation through the production of IL-10.Considering their critical role in promoting peripheral tolerance and suppressing the development of type II inflammatory responses that drive allergic disease, we sought to evaluate whether Th2 GC conditions were capable of inducing the expansion of IL-10 + Breg using human mucosal B cells.Methods: Human tonsillar B cells were cultured for 2 to 5 days at a concentration of 2 × 10 6 cells/ml in 12-well plates.Cells were stimulated with or without anti-CD40 (1ug/mL, purified from the G28.5 cell line), IL-4 (100U/mL), IL-21 (50 ng/mL) or CpG ODN 2006 (5ug/mL).For intracellular cytokine detection by flow cytometry, 50 ng/ml PMA, 1ug/ml ionomycin and 2uM GolgiStop were added for the last 5 h of culture.IL-10 secretion was assessed by ELISA and ELISpot.Results: Compared to CpG + anti-CD40, a well-cited method for the induction of human regulatory B cells, stimulation with anti-CD40 + IL-4 + IL-21 resulted in a robust induction of CD19 + IL-10 + Breg.Class-switched plasmablasts defined the primary Breg subset within the CD19 + IL-10 + CD27 + IgD-population in response to both CpG + anti-CD40 and anti-CD40 + IL-4 + IL-21 on Day 2; however, this population persisted until Day 5 only in response to stimulation with anti-CD40 + IL-4 + IL-21.Conclusions: Results identified anti-CD40 + IL-4 + IL-21 as a novel highly effective condition for the induction of human regulatory B cells and suggests a role for these cells in the regulation of Th2 GC responses.The induction and maintenance of regulatory plasmablasts in response to GC cytokines raises questions regarding the role of these cells in the suppression of IgE-mediated inflammation and whether a deficiency in this response may contribute to the pathophysiology that characterizes allergic disease.

Stimulation of human mucosal B cells with germinal center cytokines results in the generation of
studies highlighted vaccine hesitancy due to possibility of an allergic reaction.Additionally, the present review also highlights research on incidents/details of vaccine-related allergic reactions and risk assessment studies of possible allergic reaction to the COVID-19 vaccine.COVID-19 vaccine acceptance among individuals living with allergy and those with no previous known allergic disease history, is influenced by the fear of an allergic reaction.Conclusions: Despite the low prevalence rates of serious vaccinerelated adverse reactions, fear of allergic reactions to the COVID-19 vaccine remain to be one of the leading causes of vaccine hesitancy.Therefore, it is imperative to dispel misinformation and ensure that the appropriate information is promoted correctly and widely to reduce vaccine hesitancy.
Background: Environmental exposure chambers (EECs) are valuable clinical tools.They provide a controlled yet naturalistic environment to study allergen-induced symptoms.The current study compared the symptoms reported in EEC to those symptoms in natural pollen season.Methods: This study consisted of 7 scheduled visits to the study site, including a medical screening visit; Four EEC visits in which Total Symptom Score (TSS (24) = Total Nasal Symptom Score (12,TNSS) + Total Non-Nasal Symptom Score (12,TNNSS)) were collected over 3 h with grass pollen exposure (3500 ± 500 pollen grains/m 3 ); and 2 site visits flanking an at-home assessment of TSS during peak grass season.Subjects also reported the time spent outdoors (6 days).Symptoms were reported on the same electronic patient data acquisition device.Average TSS collected over the EEC sessions and peak grass allergy season (2015) by same subjects were compared.Pearson correlation analyses were performed.Results: The average TSS for subjects in the EEC and during a 6-day period in the field was less variable in EEC than in field.Subjects who reported spending > 3 h outdoors had higher average TSS than subjects < 3 h.A low correlation (non-significant) was observed between reported TSS in the EEC and TSS for subjects who spent < 3 h outdoors (r = 0.2131).There was a strong and highly significant correlation between TSS in the EEC and TSS for subjects spending > 3 h outdoors (r = 0.51, p < 0.0001).Conclusions: There is a high correlation between each subject's response in the EEC and their response in the Field for those who reported at least 3 h outdoors.Conversely, those subjects who spent less time outdoors did not develop adequate symptoms and did not correlate with their response in the EEC.This further supports the use of the EEC to ensure patients are included in allergy trials who have an adequate level of symptoms to test allergy treatments.

A qualitative investigation into vaccine hesitancy and confidence amongst people managing allergy
Kaitlyn A. Merrill 1,2 , Ayel Luis R. Batac 1,2 , Nicole Askin 3 , Michael A. Golding 1,2 , Elissa M. Abrams 1,2,4 , Phillipe Bégin 5,6 , Moshe Ben-Shoshan As such, vaccine hesitancy poses a threat to global health.Despite the rarity of allergic reaction to COVID-19 vaccines, people with allergies may still hold reservations.We aimed to describe the perceptions of COVID-19 vaccines amongst individuals managing allergy.Methods: Semi-structured qualitative interviews regarding COVID-19 vaccines were conducted with two categories of participants (all eligible for vaccination): (1) parents of children with allergies, (2) adults with allergies.Participants were recruited via social media.Transcripts were analysed independently by two researchers utilizing thematic analysis.Results: At this time, eight interviews have been conducted (n = 5 parents of children with allergies; n = 3 adults with allergies).All participants (and eligible children of participants) have been vaccinated, with a range of allergies, including food and drug allergies.Thus far, three major themes have been identified: (1) limited resources available regarding allergies and COVID-19 vaccines caused distrust, and ultimately delay, in vaccination, (2) specific allergic disease history not reflected in clinical trials or published literature increased vaccine hesitancy, and (3) allergists' advice enhanced confidence in obtaining the vaccine.Many participants cited medical professionals, government, and researchers as reputable sources to obtain information surrounding vaccines, despite significant misinformation in the media.Allergy community groups, such as Facebook groups for parents with food allergies, served as social supports and influenced the decision making of others in similar positions.Conclusions: Despite evidence of the safety of COVID-19 vaccines for those with allergies, vaccine confidence was initially shaken due to gaps in resources, professional medical advice, and representation in the literature.Ultimately, the decision to be vaccinated often was influenced by diverse stakeholders, including medical professionals, scientists, and governmental organizations, as well as community groups.Knowledge translation efforts should address the identified gaps to reduce the spread of misinformation.

Safety of Covid-19 vaccines and effect of Covid-19 infection in patients with mastocytosis
Alex Nguyen 1 , Catherine K. Zhu 1 , Emilie Groulx-Boivin 1 , Connor Prosty 1 , Sofianne Gabrielli 1 , Vera Laboccetta 2 , Pasquale Mulé 3 , Michelle Le 4 , Elena Netchiporouk 4 , Xun Zhang 2 , Reman Hak 5 , Greg Shand 2 , Sharon Baum 5 , Shoshana Greenberger 6 , Moshe Ben-Shoshan Background: Mastocytosis is characterized by abnormal clonal mast cell proliferation.Given the paucity of data and concern of anaphylaxis in patients with mastocytosis, it is crucial to assess the safety of COVID-19 vaccines in this population.We aimed to assess the risk of allergic reactions and the effect of COVID-19 infection and vaccines among patients with mastocytosis.Methods: Participants were recruited from the Mastocytosis Registry (MASTER; Canada) and Sheba Medical Center (Israel) between December 2021 to May 2022.Consenting participants were administered standardized questionnaires querying: whether they were infected with COVID-19 and reported symptoms, if they received the first and second dose vaccines, and post-vaccination side effects including allergic reactions (urticaria/angioedema, current rash flaring and/or need for updosing medications, or respiratory symptoms) and common side effects including injection site pain and flu-like symptoms.

Mimicker of cellulitis: colophony induced allergic contact dermatitis
Vivian Szeto 1 , Madeleine Smee 2 , Gordon Sussman 2 1 Western University, London, ON, 2. University of Toronto, Toronto, ON Correspondence: Vivian Szeto Allergy, Asthma & Clinical Immunology 2024, 20(Suppl 2):42 Background: Colophony is a plant resin that is found in over 300 different types of products.It is a known allergen that causes bronchial asthma in those exposed to colophony fumes and allergic contact dermatitis in those who use band-aids, anti-wart agents and musicians who play string instruments.Allergic contact dermatitis is also a known mimicker of cellulitis.Differentiating features between the two include: increased rubor and heat in cellulitis, while in allergic contact dermatitis there is more pruritus, presents with tiny vesicles, weeping, fissuring, and crusting of the skin.In this case report, we present a patient with an erythematous lesion with overlying bullae that was initially treated as cellulitis.Methods: Written informed consent was obtained from the patient for the publication of these details.Results: 67-year-old male was stung by an unidentified insect in the posterior aspect of his upper left leg.He was treated with Polypsorin and applied a band aid over the site for a week and a half.He subsequently developed erythema and bullae that spread to the medial and anterior aspect of his left leg.He was assessed at a walk-in-clinic and diagnosed with cellulitis.He was treated with oral cephalexin and transitioned to IV ceftriaxone due to lack of improvement.Patch skin test was performed to (1) paper tape (2) colophony (3) Shoppers Drug Mart band Aid (4) neomycin sulfate (5) Bacitracin.He tested positive to colophony and negative to the other agents with appropriate responses to positive and negative controls.Conclusions: In this case, the patient has been counselled on different products that contain colophony and to avoid them moving forward.This case also highlights the importance of recognizing colophony allergy to increase early removal of the allergen.As well, it reviews the different clinical features between allergic contact dermatitis and colophony.Background: Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects children and adults.Poor treatment adherence in AD requires interventions to promote self-management; patient education in chronic diseases is key to self-management.Many international AD management guidelines published to date include a recommendation for educating patients as part of their treatment but there are no formal recommendations on how to deliver this knowledge.Methods: A scoping review was performed in the online databases MEDLINE and Ovid in October 2021.The search strategy yielded 388 articles.Of the 388 articles screened, 15 studies met the eligibility criteria, and the quantitative data was summarized by narrative synthesis.

Results:
The majority of studies were randomized controlled trials conducted in Europe, Asia and North America.Since 2002, there have been limited studies evaluating patient education in the treatment of AD.Frequent education methods used included groupbased educational programs, educational pamphlets, individual consultations and online resources.Education was most commonly directed at caregivers and their children.Only one study compared the efficacy of different education methods.In all included studies, the heterogenous nature of outcome measures and study design limited the consistency of results.Despite the heterogeneity of studies, patient education was shown to improve quality of life (QoL), disease severity and psychological outcomes in AD patients.Conclusions: This scoping review highlights that patient education is effective in a variety of domains relevant to AD treatment.Further comparative studies and randomized trials with longer-term follow-up are needed to provide validated and consistent patient education recommendations for AD; these may depend on age and population.
Background: Idiopathic hypereosinophilic syndrome (HES) is defined as eosinophilia associated with organ involvement in the absence of a secondary cause or a recurrent genetic abnormality.Recently, mepolizumab has been approved in Canada as the only targeted biologic therapeutic for the treatment of adult patients with idiopathic HES.Case presentation: A 20-year-old otherwise healthy Caucasian female with no recent travel or occupational exposures was referred with an 18-month history of rhinitis, dyspnea, and exercise intolerance.Spirometry demonstrated an FEV1 of 83% with borderline obstruction.There was serum eosinophilia with an increase in absolute eosinophil count (AEC) 1.5 × 10 9 /L to 4.6 × 10 9 /L over 1 month.A workup of secondary causes was negative.Vitamin B12, C-reactive protein, serum tryptase, immunoglobulin levels, antinuclear antibody levels and antineutrophil cytoplasmic antibody levels were normal.Serology for HIV and strongyloides was negative.There was no biochemical evidence of adrenal insufficiency (normal AM cortisol).Her kidney and liver function were normal, and no organomegaly was identified with computed tomography scans of the thorax and abdomen.However, an echocardiogram revealed pericarditis necessitating a referral to Cardiology for assessment of end-organ dysfunction.She was also referred to Hematology for bone marrow biopsy, during which her AEC rose to 12.2 × 10 9 /L.Her marrow showed marked eosinophilia.No PDGFRA or PDGFRB rearrangement and no clonal abnormalities were detected.She failed treatment with high-dose prednisone and methotrexate, and is now on mepolizumab with improvement.Conclusions: Morbidity and mortality from HES results from tissue infiltration by eosinophils and subsequent organ dysfunction from eosinophil degranulation.The relationship between eosinophilia duration and severity is not well established, but an AEC greater than 1.5 × 10 9 /L has been recommended as a threshold for starting treatment.Mepolizumab should be considered as a treatment option in patients who fail first-line therapy with glucocorticoids.Background: Atopy is a state of general immune hyperresponsiveness and IgE may be involved in cancer immunosurveillance.Higher serum IgE levels correlate with a decreased malignancy risk and prolonged survival in cancer patients.Conversely, IgE deficiency is associated with an increased risk of cancer, such as breast and ovary.Omalizumab is an anti-IgE monoclonal antibody indicated for chronic spontaneous urticaria (CSU) and atopic asthma.While a theoretical cancer risk has been suspected in patients receiving Omalizumab data from post-marketing studies and systematic reviews have not substantiated this.Case presentation: We present a G1P1 37-year-old female with severe, refractory CSU and angioedema.Her quality of life drastically improved after starting omalizumab.The patient desired another pregnancy, and after failed attempts at discontinuing Omalizumab, a decision was made to conceive while on treatment.Her second pregnancy was a blighted ovum, abortion was induced at 8 weeks gestation.Her third pregnancy was an invasive mole that transformed into choriocarcinoma requiring surgical removal and chemotherapy.A pedigree revealed strong family history of malignancy, particularly her mother who had choriocarcinoma at 49 and breast cancer at age 51.Genetic work-up for hereditary cancer syndromes did not reveal any pathogenic variants.Given the refractory nature of her urticaria, a decision was made to continue the Omalizumab with increased cancer surveillance.

Conclusions:
This patient likely developed choriocarcinoma because of a cancer predisposition syndrome.However, contribution of Omalizumab cannot be excluded.Some limitations of pre-existing studies on Omalizumab and malignancy include selection bias, lack of pre-enrolment data, and short observation period.A recent disproportionality analysis suggested that omalizumab may be associated with increased cancer risk.Discussing a theoretical yet clinically unquantifiable and unsubstantiated neoplastic risk with all patients prior to stating Omalizumab is unjustified and likely harmful.However, disclosing this possibility may be appropriate for certain patients to ensure shared decision making.

Statement of Consent
Written Informed Consent for this case report was obtained from the patient.

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Elevated tryptase level in a child with idiopathic anaphylaxis: a case of hereditary alpha tryptasemia Vicky LeBlanc 1,2 , Wade Watson Background: Hereditary alpha-tryptasemia (HaT), caused by increased copies of TPSAB1, is a autosomal dominant disorder affecting approximately 5% of the general population.Elevated baseline tryptase level is a consistent finding among affected families.However, clinical features differ greatly among individuals.While some are asymptomatic, others complain of functional gastrointestinal symptoms, recurrent cutaneous manifestations or constitutional symptoms.HaT has also been associated with increased severity of venom anaphylaxis, systemic mastocytosis (12%) and idiopathic anaphylaxis (17%).Uncertainty remains around the clinical phenotype of HaT.Case presentation: We describe a 5 year 8 month girl with 2 episodes of idiopathic anaphylaxis manifesting by urticaria, angioedema, pruritus and emesis.First episode occurred after swimming for one hour and the second, 48 h after an acute febrile illness.The second episode required 2 doses of epinephrine for symptoms to resolve.Despite a detailed history, no allergic trigger could be identified.The tryptase level during the second episode was elevated at 31.2 mg/L.Baseline tryptase levels were measured twice at 22.7 and 20.6 mg/L.She is otherwise healthy, non-atopic child, with no other complaints.A meticulous physical examination revealed no sign of lymphadenopathy or hepatosplenomegaly.Only one small hyperpigmented area was identified on her left leg, but Darier's sign was negative.Investigations included normal complete blood count, normal liver and renal functions and negative genetic testing for KIT mutation.Baseline serum tryptase levels were measured in both parents.Her mother had a normal level of 7 mg/L and her father had an elevated level of 17 mg/L.He has no symptoms.Conclusions: In conclusion, HaT is a condition with a great spectrum of clinical manifestations.While idiopathic anaphylaxis is not a common presentation, it should be considered in patients presenting with recurrent idiopathic anaphylaxis.

Statement of consent
Written Informed Consent for this case report was obtained from the patient's guardian.

Background:
The benefits of flaxseed (linseed) as a source of fiber and omega-3 fatty acids makes it a popular superfood that has garnered interest as an egg-substitute when prepared by mixing ground flaxseed with water.The increased prevalence of flaxseed in the diet has led to concerns that flaxseed is an emerging allergen.Although sensitization and anaphylaxis to flaxseed have previously been reported, we report the first case of anaphylaxis to ground flaxseed used as an egg-substitute in a pediatric patient who regularly consumes whole flaxseed.Written informed consent for publication was obtained.Case presentation: A 10-month-old girl with atopic dermatitis was assessed at the BC Children's Hospital Allergy Clinic after she developed lethargy, projectile vomiting, and generalized urticaria within 15 min of consuming a small bite of vegan muffin.Symptoms spontaneously resolved within an hour.She had no further exposure to the muffin nor any anaphylactic events.Potential allergenic foods in the muffin included walnut and flaxseed, the latter of which was ground and baked into the muffin as an eggsubstitute.As she tolerated whole flaxseeds several times per week but had not yet introduced tree nuts to her diet, walnut was suspected to be the allergen.However, skin prick test (SPT), serum specific IgE, and oral food challenge to walnut were negative.Instead, flaxseed allergy was diagnosed with a positive SPT of 12 × 6 mm and serum specific IgE of 51.1 kU/L; its avoidance was recommended.Conclusions: Whole flaxseed may be tolerated in patients allergic to ground flaxseed due to its hard outer coat which prevents it from being digested and exposing the allergen; similar findings were noted in sesame-allergic patients.Inquiry of ground or whole flaxseed consumption during food allergy assessments and careful review of ingredients in foods made with substitutions are advised.Background: The avoidance of causative agent in food proteininduced enterocolitis syndrome (FPIES) management is discordant to the recommendation of early and regular consumption of allergenic foods to prevent food allergies.Consequently, IgE-mediated reactions have occurred after FPIES for cow's milk.Reports of such reactions with eggs are limited.Our case adds to this limited literature along with an atypical worsening of FPIES reaction over time.Written informed consent for publication was obtained.Case presentation: A 10-month-old girl was diagnosed with FPIES to egg with negative skin prick test (SPT) at the BC Children's Hospital Allergy Clinic after two episodes of recurrent projectile vomiting, pallor, and non-bloody diarrhea occurring 3 to 4 h after egg consumption at ages 7 and 8 months, requiring intravenous rehydration and antiemetics.She was reassessed at 21 months with an oral food challenge (OFC) to scrambled egg.She developed a single vomiting episode at 4 h, which was treated with sublingual ondansetron and oral rehydration.Skin testing to egg was repeated prior to FPIES challenge at 37 months given her history of atopic dermatitis.This revealed new sensitization to egg white (5 × 4 mm) and yolk (3 × 3 mm).French toast containing 1 egg was given in incremental doses for OFC given her sensitization.A crumb-sized portion was tolerated.10 min after consuming 1/16th of the French toast, she developed 3 to 4 urticaria on her face and back which resolved in 20 min.After 3 h, she developed significant projectile vomiting, pallor, and lethargy requiring transfer to the emergency room for intravenous rehydration and antiemetics.Conclusions: New IgE-mediated reaction to egg was observed after its avoidance for FPIES, suggesting that SPT prior to OFC in atopic patients and counselling on the risk of developing new IgE-mediated allergy secondary to strict avoidance is prudent.Background: Eosinophilia with multiple organ involvement characterizes a wide yet specific group of atopic, infectious, neoplastic, and immunologic disorders.Eosinophilic granulomatosis with polyangiitis (EGPA) is one such vasculitic disorder with respiratory tract manifestations including asthma and rhinosinusitis.When there is a lack of evidence for other known causes of eosinophilia, the diagnosis of hypereosinophilic syndrome (HES), which describes a rare group of disorders defined by sustained hypereosinophilia over six months and evidence of organ involvement, can be considered.In general the treatment of HES is dependent on etiology, however a novel indication allows Il-5 monoclonal antibody therapy to be used when there is no identifiable non hematologic secondary cause.Case presentation: We describe a case of idiopathic hypereosinophilic disorder in a 24 year old asthmatic male presenting with chronic rhinosinusitis, aphthous stomatitis, eosinophilic cellulitis, gastrointestinal involvement, and elevated IgG4 without identifiable underlying etiology of eosinophilia despite extensive workup.Features of EGPA were predominant however the lack of vasculitic evidence precluded this diagnosis.While Well's syndrome was proposed to describe his cutaneous manifestations, it was not sufficient to account for his presentation.Our patient achieved remarkable clinical improvement of symptoms and corticosteroid independence with mepolizumab.There was no recurrence of symptoms at 8 month follow-up.Conclusions: While this case behaves like a secondary eosinophilic disease and shares many characteristics with EGPA, the absence of vasculitis and other disease criteria necessitates the diagnosis of idiopathic hypereosinophilic syndrome.Our case contributes to the growing base of literature on the efficacy and long term safety of mepolizumab for idiopathic hypereosinophilic syndrome.

Statement of consent
Written Informed Consent for this case report was obtained from the patient.

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Bear meat anaphylaxis: a case report Ariana Mustillo 1 , Michael Fein Background: Meat allergy is uncommon and bear meat allergy is comparatively exceedingly rare.It has exclusively been reported within the context of a larger family of mammalian meat IgE-mediated allergy involving galactose-a-1,3-galactose(alpha-gal), typically associated with delayed symptom onset after meat ingestion.Here we report the first case to our knowledge of a non-alpha-gal related bear meat allergy.Case presentation: A 46-year-old Cree male with no significant prior medical history, no history of atopy or known allergies presented with a suspected anaphylactic reaction to bear meat.Fifteen minutes after ingestion of boiled black bear meat, the patient developed throat swelling, shortness of breath, nausea, vomiting and weakness.He had no urticaria or angioedema.He was treated in his local community and received two doses of intramuscular epinephrine with complete resolution of symptoms within an hour after treatment.All other persons who consumed the bear meat did not develop any reaction.The patient had since avoided bear meat, but has tolerated every other consumed meat, including beef, rabbit, and moose.He also developed localized leg swelling when he applied bear fat to his skin.The patient was later assessed for skin testing in our allergy clinic.He had a positive skin prick test (SPT) to boiled black bear meat with a 6 mm wheal and a negative saline control.Aeroallergens were also tested by SPT, which were positive for cat (9 mm), dust mites (D.Farinea 8 mm; D. Pteronyssinus 7 mm) and cockroach (7 mm) with no associated symptoms of allergic rhinitis.Conclusions: The rapid symptom onset and tolerance of other mammalian meat rules out alpha-gal as a culprit in this patient's bear meat allergy.To our knowledge, this is the first report in the literature of an allergy specifically to bear meat and clinicians should be aware of the existence of this entity when evaluating patient's for meat allergy.Background: Acute respiratory manifestations of COVID-19 infection have been well documented.Other organ systems may also be adversely affected.However, there is a limited understanding of the extent and management of extrapulmonary COVID-19-related conditions.Infection-related rhabdomyolysis is rare but be seen as a manifestation of COVID-19.The case below highlights COVID-19 infection presenting as rhabdomyolysis in Trinidad and Tobago.Case presentation: A 40-year-old male presented with generalized muscle pains for 4 days associated with dark coloured urine and intermittent fever.There were no pulmonary symptoms and he denied any recent strenuous activity or exercise.Past medical history was positive for Hepatitis A. Drug history included simple analgesics.His vaccination status was up to date as per local guidelines.Cardiac and respiratory examinations were normal.Urinalysis was strongly positive for blood.Lab investigations revealed a normal complete blood count, troponin I, renal and hepatic function.Chest radiograph and abdominal ultrasound scans were also normal.PCR for Covid-19 was positive together with a severely elevated creatine kinase (CK) value of 193,792 U/L.A diagnosis of rhabdomyolysis was made, intravenous fluid therapy was initiated and he was transferred to the intensive care unit.Serial labs were performed to monitor CK and renal function.CK trend showed steady decline reaching a value of 2762 U/L on day 8.There was resolution of symptoms and he was discharged to return for outpatient follow up.Conclusions: Non-specific symptoms of myalgia and arthralgia occur often in viral illnesses.In Covid-19 infection these symptoms can occur without respiratory involvement and should herald the screening for rhabdomyolysis to rule out this critical extrapulmonary manifestation.

Statement of consent
Written Informed Consent for this case report was obtained from the patient.There have been some case reports of ANCA-associated vasculitis (AAV) following COVID-19 vaccinations.It is a rare but important complication that can present similarly to COVID-19 infection.We present the first case in Canada of AAV following COVID-19 vaccination with worsening renal function upon receiving the second dose vaccination.Case presentation: We report a case of a 38-year-old-male who developed respiratory and flu-like symptoms within 3 weeks of receiving his first dose of Pfizer-BioNTech COVID-19 mRNA vaccine.He had persistent progressive symptoms which were initially attributed to possible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.This led to a considerable diagnostic delay.He eventually presented to an emergency department approximately 8 weeks after symptom onset.He had pulmonary and renal involvement.Bronchoscopy and renal biopsy ultimately confirmed the diagnosis of proteinase 3 (PR3) antibody, anti-neutrophil cytoplasmic antibody (ANCA)-positive, eosinophilic granulomatosis and polyangiitis (EPGA).Despite being on systemic glucocorticoid therapy, he had worsening renal failure after receiving his second dose of Pfizer-BioNTech COVID-19 mRNA vaccine.The patient had renal recovery after starting rituximab in addition to continuing oral glucocorticoids.Conclusions: As COVID-19 vaccination programs continue for the foreseeable future, there will likely be more cases of AAV following COVID-19 vaccines.While direct causality cannot be proven, our case raises the suspicion with strong temporal association that COVID-19 vaccine may likely have triggered an autoimmune response.We highlight the importance of early diagnostic work-up and considering the diagnosis EGPA when patients present with unexplained pulmonary renal disease following COVID-19 vaccination.

Statement of consent
Written Informed Consent for this case report was obtained from the patient.

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Dupilumab induced psoriasis in a patient with atopic dermatitis: a case report Madeleine Smee 1 , Khaldon Abbas 2 , Gordon Sussman Background: Atopic dermatitis (AD) is a common skin disease characterized by chronic inflammation and pruritus due to hypersensitivity of skin and mucous membranes.Dupilumab is an IgG4 monoclonal antibody that inhibits interleukin (IL)-4 and IL-13 signalling and is used to treat AD.Common side-effects include injection site reactions, conjunctivitis, and keratitis.Additionally, several cases of psoriasis developing after treatment with dupilumab have been recorded.Psoriasis is characterized by excessive growth of epithelial cells into plaques that constantly shed.We describe a case of new onset psoriasis following dupilumab treatment.Case Presentation: A 55-year-old female was initially seen in 2018 for severe unresponsive AD that covered 50-75% of her skin surface area.She had failed first-, second-, and third-line treatments prior to dupilumab.Failed treatments included antihistamines, topical steroids, and Omalizumab.Dupilumab was initially prescribed for 150 mg every two weeks but frequency was increased to weekly after six months without clinical response.She had significant clinical improvement and her AD became completely controlled, however four years after starting dupilumab she developed psoriasis.Her psoriasis is severe, generalized, and mainly affects the lower limbs and buttocks.It is well-demarcated, patchy, with thick white scale.The patient wished to continue therapy with dupilumab despite side effects because of success in clearing her AD.To date, the psoriasis persists.Conclusions: The patient is under further investigation on how to effectively treat her AD without triggering psoriasis.This case highlights a lesser-known reaction to dupilumab, and promotes caution in the initiation of Dupilumab therapy in patients with AD and concurrent psoriasis.

Statement of consent
Written Informed Consent for this case report was obtained from the patient 59 Preadolescent with red dragonfruit allergy without previous ingestion history Joanne Wang, Godfrey Lam University of British Columbia, Vancouver, BC Correspondence: Joanne Wang Allergy, Asthma & Clinical Immunology 2024, 20(Suppl 2):59 Background: Dragon fruit belongs to the Cactaceae family located in Central America and Asia.Nonspecific lipid transfer proteins (nsLTPs) are ubiquitous in plants and can cause systemic reactions to plant foods in sensitized individuals.Previously, pitaya nsLTP has been identified as an allergen causing anaphylaxis.Case presentation: An 11-year-old female, with history of atopic dermatitis, allergic rhinitis, consumed a red dragonfruit for the first time.She developed periorbital swelling, generalized urticaria, and subjective dyspnea within two hours of ingestion.She did not require epinephrine, and her symptoms improved within 24 h.She saw her general physician, who recommended she avoid dragonfruit, kiwi, and passionfruit.Prior to this, she was tolerating kiwifruit and passionfruit infrequently without reactions.Patient was assessed in the allergy clinic, where she was found to have positive epicutaneous skin tests to grass pollen, dust mite dander, and dragon fruit (fresh food, 6 mm).She was also found to have positive sIgE to kiwifruit (0.66 KU/L) and passionfruit (0.61KU/L).Based on history and skin test results, she has a confirmed dragonfruit allergy.Her low titre sIgE to kiwifruit and passionfruit may be sensitization rather than true allergies.She was offered oral food challenges to these in the future.Conclusions: Dragonfruit allergy is rare.To our knowledge, only three cases have been documented thus far.NsLTP is one of the most frequent causes of primary food allergies given its widespread distribution throughout the plant kingdom in botanically unrelated foods.NsLTP was identified as an allergen in pitaya in one case.Our patient has never ingested dragon fruit, and her sensitization may have occurred via nsLTPs in other plant foods (kiwifruit) or pollens (grass).Her sensitisation to kiwifruit, in particular, is interesting as Zhu et al. previously described a patient with kiwifruit anaphylaxis who was also allergic to dragon fruit suggesting possible shared protein.

Statement of consent
Written Informed Consent for this case report was obtained from the patient's guardian.Background: Patients with chronic spontaneous urticaria (CSU) are more likely to have elevated levels of aeroallergen sensitization, blood eosinophil %, total IgE, and IgG autoantibodies to FcεR1α, IgE and thyroid peroxidase, indicating the importance of T2 inflammation in the pathogenesis of CSU.Case presentation: We describe a 44-year-old female with recurrent CSU, allergic rhinitis (AR), intermittent asthma and previous ethmoid sinusitis on CT.In December 2019, she presented to the ED with lip and tongue angioedema and generalized urticaria, with no clear trigger.She received epinephrine intramuscularly and was discharged on prednisone.
An autoimmune screen was positive for autoantibodies to thyroglobulin and dsDNA.Her TSH was normal and C3 was low.Her IgE was 11 kIU/L (normal < 87).Her blood eosinophil count was 0.3 × 10 9 /L (normal < 0.4), but her blood eosinophil percentage was 5% (normal < 4%).Skin prick tests had been positive to grass, ragweed, and dust mite.This patient was counselled on allergen avoidance and started on intranasal fluticasone furoate and montelukast for her nasal congestion, and rupatadine for her CSU.Her CSU and AR worsened during the 2020 grass and ragweed pollen seasons.During summer 2020, she experienced two CSU flares requiring prednisone.We increased her rupatadine dosage and started inhaled fluticasone furoate to control asthma symptoms.She was offered omalizumab but declined.By 2021, her CSU symptoms markedly improved.She required only one course of prednisone during ragweed season and had better control of her hives in grass season.Since October 2021, she has been off all medications and has not experienced any flares until spring 2022, when she decided to initiate ragweed sublingual immunotherapy.Conclusions: This patient's urticaria deteriorated seasonally and improved with managing her mucosal allergic inflammation.Specific allergen avoidance and desensitization may be beneficial in the management of CSU.

Statement of consent
Written Informed Consent for this case report was obtained from the patient 61 Omega 5 gliadin allergy: are there differences in whole wheat vs white flour?Kavya Yatham 1 , Juan Ruiz 2 1 University of Saskatchewan, Saskatoon, SK; 2 University of British Columbia, Vancouver, BC Correspondence: Kavya Yatham Allergy, Asthma & Clinical Immunology 2024, 20(Suppl 2):61 Background: Omega 5 gliadin (O5G) allergy is an uncommon allergy to a component of wheat that can result in anaphylaxis, typically in the presence of a cofactor.Making the diagnosis can be difficult, as patients can present various allergic manifestations and may be unknowingly exposed to wheat.The most common cofactors identified are exercise, alcohol, and nonsteroidal antiinflammatory drugs.A small number of cases have no identifiable cofactor found.Case presentation: We present a case of a 23-year-old female with recurrent hives, GI upset, vomiting, and presyncope to multiple foods over two years.These symptoms all occurred within one hour of ingestion of various foods.She experienced no hives outside of these instances.She had experienced seven episodes of anaphylaxis with no apparent trigger.Skin prick testing was positive to white, milled, and gluten flour; negative to wheat and other grains such as rye, barley, and oat.IgE testing to O5G IgE/Tri a 19 (5.20 kU/L) was positive.She has continued to eat whole wheat products regularly with no anaphylaxis but has reacted to ingesting flour products such as hamburger buns, French baguettes, and pizza.We considered the possibility of flour mite anaphylaxis however it is unlikely that she would react to many different types of flour products and consistently react to white flour products from various sources.She failed an oral challenge to white flour in the form of baked pizza.Within one hour of ingestion, she developed disseminated hives.Conclusions: We present a case of O5G allergy with multiple episodes of anaphylaxis with no identifiable cofactor.Of particular interest, the patient never reacted to eating whole wheat products.We hypothesize that there may be differences in the processing of whole wheat flour versus white flour and the content of O5G in such products.

Statement of Consent
Written Informed Consent for this case report was obtained from the patient.

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Development of IgE-mediated reaction to egg after its avoidance for food protein-induced enterocolitis syndrome: case report Kevin K. Lee, Stephanie Erdle The University of British Columbia, Vancouver, BC Correspondence: Kevin K. Lee Allergy, Asthma & Clinical Immunology 2024, 20(Suppl 2):53

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An usual presentation of idiopathic hypereosinophilic syndrome with features of eosinophilic granulomatosis with polyangiitis and substantial response to mepolizumab Adhora Mir, Timothy Olynych University of Ottawa, Ottawa, ON Correspondence: Adhora Mir Allergy, Asthma & Clinical Immunology 2024, 20(Suppl 2):54 Pfizer-BioNTEch COVID-19 mRNA vaccination Jane Park, Stephen Betschel Division of Clinical Immunology and Allergy, Department of Medicine, University of Toronto, Toronto, ON Correspondence: Jane Park Allergy, Asthma & Clinical Immunology 2024, 20(Suppl 2):57 Background: The global pandemic with coronavirus disease 19 (COVID-19) continues and massive vaccination programs against COVID-19 have become the mainstay of public health measures.

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Role of treating allergic rhinitis and asthma in a patient with chronic spontaneous urticaria Melanie M. Wong 1 , Paul K. Keith 2 1 Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON; 2 Department of Medicine, McMaster University, Hamilton, ON Correspondence: Melanie M. Wong Allergy, Asthma & Clinical Immunology 2024, 20(Suppl 2):60

13 Comparing relative allergen content and specific IgE binding in protein extracts from crushed peanut versus bamba
Conclusions: AD education programs are rare and providing education can help to improve management of children's AD.Information, treatment demonstration, and support provided to families can improve adherence to and efficacy of AD treatment.Virtual sessions are an effective way to increase knowledge and positively affect behavior change for eczema management.Educators play an ongoing role in supporting and educating families with AD.
Background: BC Children's Hospital Allergy Clinic provides longitudinal care to ensure patients are adherent and tolerating food allergy immunotherapy (FAIT).Scheduled follow-up visits occur during buildup and infrequently at maintenance, but between these appointments there is little communication between the patients and their healthcare team, relying on families to inform the clinic if there are issues.Increasing proactive communication with patients might reduce patient/caregiver anxiety and improve treatment adherence.

:
Our findings suggest that parental concern is significantly affected by pediatric OIT, but global Health-Related Quality of Life (HRQL) is not.

protein penetration rates of peanut sublingual immunotherapy preparations
Despite the increasing number of cases of secondary immunodeficiency and immunoglobulin utilization, there is a paucity of data in the literature on clinical outcomes and patient-reported health-related QoL measures in this population.This is the first report from the Ontario Immunoglobulin Treatment (ONIT) registry, a multicentre program based at Ottawa, Hamilton and Toronto, on patients with secondary immunodeficiency.
Brock A. Williams, Yigong Guo, Lianne Soller, Edmond S. Chan, Anubhav Pratap-Singh The University of British Columbia, Vancouver, BC Correspondence: Brock A. Williams Allergy, Asthma & Clinical Immunology 2024, 20(Suppl 2):23 Background: Methods: Cross-sectional study of patients with secondary immunodeficiency enrolled in the ONIT Case Registry from June 2020 to March 2022 was completed.Demographics, comorbidities, indication for immunoglobulin treatment, clinical data infections, and patientreported quality of life parameters were collected and analyzed.Results:A total of 108 patients (45 male; 63 female; average age of 66) with secondary immunodeficiency as the main indication for IG treatment were identified.Of these patients, 93 were on SCIG (of whom 19 were previously on IVIG) and 15 were on IVIG.The most common indication was CLL (N = 33), followed by lymphoma (N = 20) and transplant (N = 11).92% of patients were followed by one or more subspecialists, with the most common being hematology/oncology (62%).SCIG average dosage was 0.57 ± 0.30 g/kg/4 weeks and IVIG average dosage was 0.49 ± 0.15 g/kg/4 weeks.IG treatment reduced average annual number of infections by 83% (4.3 vs. 0.7) and the number of emergency department visits by 85% (1.3 vs 0.2).91.7% of the patients who switched from IVIG to SCIG reported their health as same or better compared to before the switch.Overall, 80.5% of patients reported their health as better compared to before they started immunoglobulin treatment.Conclusions: To our knowledge, this is the largest cross-sectional descriptive study reported on patients with secondary immunodeficiency receiving IG treatment in Canada.IG treatment has improved clinical and quality of life reported outcomes.The data reported here can be invaluable in improving care coordination and management of these complex patients.IgM(n = 14), IgG(n = 15), respectively after the removal of outliers (S1 for negative control sample for IgA and IgG and RBD for blank well for IgG).Conclusions: The mean intra-assay %CV for all targets were < 10% except for IgG for CB3.The mean inter-assay %CV were < 12% after the removal of the aforementioned outliers.The intra-and inter-assay %CV were lower than the manufacturer's reported < 15% and < 20%.COVID-19 Map [Internet].Johns Hopkins Coronavirus Resource Center.[cited 2022 May 5].Available from: https:// coron avirus.jhu.edu/ map.html.

, Asthma & Clinical Immunology 2024, 20(Suppl 2):28
We demonstrate the clinical utility of genetic testing for IEI and its hematologic phenocopies.While both panels had a similar yield, the most frequent diagnostic genes are panel specific.
proprietary pipeline to detect exon-level CNVs.Variant interpretation was performed using a modification of the ACMG guidelines.Results:The BTK (9%) and STAT3 (6%) genes made up most diagnoses for the cohort tested with the PID panel.For the CIC panel, the gene responsible for the most diagnoses was XIAP (9%).CNVs were responsible for the diagnosis in 15% of patients while noncoding variants were responsible for the diagnosis in 7% of patients.Variants in difficult-to-sequence genes accounted for 10% of the diagnoses.Conclusions:

of type 2 inflammation in adult and adolescent patients with eosinophilic esophagitis in parts a and c of a three-part, phase 3 lLIBERTY EoE TREET study
Marc Rothenberg 2 , Ikuo Hirano 3 , Evan S. Dellon 4 , John Leung 5 , Jason Lee 1 , Angela Khodzayev 6 , Juby A. Jacob-Nara 7 , Danen M. Cunoosamy 8 , Jennifer D. Hamilton 6 1 Clinical Immunology and Allergy and Internal Medicine, Toronto Allergy and Asthma Clinic, Toronto, ON; 2 Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA; 3 Northwestern University Feinberg School of Medicine, Chicago, IL, USA, 4 University of North Carolina School of Medicine, Chapel Hill, NC, USA; 5 Tufts Medical Center, Boston, MA, USA; 6 Regeneron Pharmaceuticals, Inc, Tarrytown, NY, USA; 7 Sanofi, Bridgewater, NJ, USA, 8 Sanofi, Cambridge, MA, USA Correspondence: Jason Lee Allergy, Asthma & Clinical Immunology 2024,

term natural history of Good's Syndrome
Conclusions: Dupilumab suppressed TARC, eotaxin-3, and total IgE in EoE patients over 52 weeks, consistent with prior assessment in EoE and other type 2 inflammatory diseases.Placebo/dupilumab patients in Part C showed similar treatment effects to dupilumab patients in Part A. Long

, Asthma & Clinical Immunology 2024, 20(Suppl 2):40 Background:
7,8,9 , Erika Ladouceur 10 , Leslie E. Roos 11 , Vladan Protudjer 12 , Jennifer LP Protudjer 1,2,13 1 Department of Pediatrics and Child Health, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB; 2 Children's Hospital Research Institute of Manitoba, Winnipeg, MB; 3 WRHA Virtual Library, University of Manitoba, Winnipeg, MB; 4 Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, 5 Division of Allergy, Department of Pediatrics, Centre hospitalier universitaire Sainte-Justine (CHU Sainte-Justine), Montreal, QC; 6 Division of Allergy, Department of Medicine, Centre hospitalier de l'Université de Montréal (CHUM), Montreal, QC; 7 Division of Pediatric Allergy, Clinical Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC; 8 Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada, Montreal, QC; 9 Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC; 10 Science for All Audiences, Toronto, ON; 11 Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, MB; 12 College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB; 13 Department of Food and Human Nutritional Sciences, Faculty of Agricultural and Food Sciences, University of Manitoba, Winnipeg, MB Correspondence: Kaitlyn A. Merrill AllergyCOVID-19 vaccines are critical to the pandemic response.

pulmonary manifestations of Covid-19 can occur. A case report of a Covid-19 infection presenting as rhabdomyolysis in Trinidad and Tobago
Written Informed Consent for this case report was obtained from the patient.Ijaz Ogeer 1 , Meghan Lalla 1 , Joseph Zacherali 1 , Narine Mack 1 , Stanley Giddings 2

1
Augustus Long Hospital, Point A Pierre, Trinidad and Tobago; 2 University Of The West Indies, St. Augustine, Trinidad and Tobago Correspondence